Delayed Primary Closure, Part I

Since starting lacerationrepair.com, I have gotten many referrals of cases from people throughout the country with interesting questions regarding wound care. One such case I was recently referred* went like this:

An otherwise healthy forty-year-old male presented to the ED 24 hours after sustaining a laceration to his forehead. The laceration was 4 cm, with macerated edges and evidence of contamination. Without closure, it would leave a fairly sizable scar on a visible portion of the patient’s face.

The provider who initially evaluated him decided not to close the wound because of his delayed presentation, citing the time elapsed as too large of an infection risk for primary closure in the ED.

Instead, he referred the patient for a delayed primary closure (henceforth DPC), to be performed in an urgent care clinic associated with the hospital in three days time.

However, when the patient dutifully attended his follow up visit, the urgent care provider wasn’t certain about whether DPC was a feasible option. He consulted with a local plastic surgeon.

The surgeon heard the story and stated, “Absolutely not. There is no role for delayed primary closure of traumatic lacerations.” He recommended that the wound be allowed to heal by secondary intention, and the patient follow up in 6 to 12 months for a scar revision if unhappy with the cosmetic outcome. Thus the patient was left with conflicting advisement by two doctors, and a larger scar (for the time being) to boot.

Two questions were raised by this case:

(1) was the original provider’s decision not to close the wound based on delayed presentation appropriate?

(2) was the plastic surgeon correct in his assertion that there is no role for delayed primary closure in a case like this?

Glossary of terms

Before going any further, I’d like to lay out a basic glossary of terms for those not as familiar with these concepts in wound care. Wounds are generally classified (by the American College of Surgeons) as follows:

Clean (Class I): a surgically created wound, such as in an elective OR case. Another condition to be a clean wound is that it do not involve the respiratory, GI or GU tracts. Laparoscopic surgeries, skin biopsies, and vascular surgeries are some examples.

Clean contaminated (Class II): a wound involving normal tissue that is colonized by bacteria. Wounds which involve the respiratory, GI/GU tracts automatically enter this category, as do wounds opened to remove pins or wires.

Contaminated (Class III): a wound containing foreign or infected matter–the most typical situation seen in emergency departments. Gross contamination isn’t required to meet this classification, just any contact with a foreign object like a bullet, knife blade or other sharp material.

Infected (Class IV): a wound with purulent drainage. These include wounds with a foreign object lodged in the wound like pieces of metal or other debris. This class can also include traumatic wounds from a dirty source where the treatment was delayed, infected surgical wounds, or any wound exposed to pus or fecal matter.

Closure by primary intention: immediate closure of a wound, using sutures, staples, surgical tape, or tissue adhesive glue. Typically used for a clean or contaminated wound after thorough cleansing and debridement

Closure by secondary intention: allowing a wound to heal naturally without any closure methods as above. This is the usual strategy for badly contaminated wounds (such as animal bites) and infected wounds.

Delayed primary closure: A strategy of waiting to close a wound after ~48 hours, after it has proven not to have any signs of infection. This is also sometimes referred to as Closure by tertiary intention. This is a strategy typically employed for clean contaminated wounds and clean wounds that are older than 6 hours.

Question 1: was the original provider’s decision not to close the wound appropriate?

What this question really asks is, what is the true golden period for primary wound closure? When, if ever, do the risks of primary closure (due to potential wound infection) outweigh the benefits of a better cosmetic outcome with closure? Last year, I published a post describing the history of the golden period which debunks many of its applications in emergency medicine. Briefly, no precise golden period can be applied to when wound closure is absolutely contraindicated. Rather–as is often the case in medicine–it is a question of weighing the risk related to elapsed time (and bacterial colonization) versus the benefit for a given patient, area of the body, and patient values. And as it turns out, other factors such as body location on the (relatively dirtier) lower extremity, co-morbidities (specifically, diabetes), and wound length (greater than 5 cm) turn out to be much more important when it comes to infection risk!

How fast is the clock really ticking on your decision to close a laceration?

For this post, I once again reviewed the literature to see if any updates exist. Per my pubmed search today, everything written in my previous post summarizes the most up-to-date literature!

So, to answer question 1:

it is difficult to say whether the original provider’s decision not to close the wound was appropriate. One must weigh many factors in a particular case–not just wound age–in calculating the risk/benefit ratio of primary closure. I think it is always appropriate to involve shared decision-making and invoke the values and care goals of the patient as well.

In Part II, I discuss the answer to question 2: is there a role for DPC in treating a patient like this?

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*Footnote: The case described above reflects the clinical issues encountered in a real clinical encounter, to the best of my knowledge. It was referred to me by a third party. Some details of the case have been changed to protect patient identity. The discussion of the case is meant to aid medical professionals in making optimal decisions for the best care of their patients, and is not to be construed as a legal discussion. It reflects my personal opinions as shaped by the best available medical literature as of the original publication date.